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Y3 Surgery > General Surgery > Flashcards

General Surgery Flashcards

1
Q

What presentations of ‘the acute abdomen’ require urgent intervention?

A

Acute bleeding
- ruptured AAA
- ruptured ectopic pregnancy, bleeding peptic ulcer or traumatic injury

Perforated viscus
-localised perforation can often present with localised pain and peritonism, tachycardia, and pyrexia (however may not necessarily look unwell!)
- generalised peritonitis will often present with tachycardia (+/- hypotension), pyrexia, and a rigid abdomen (and will look unwell!)
- urgent resus and cross-sectional imaging required

Ischaemic bowel
- severe pain out of proportion with clinical signs
- raised lactate and acidosis
- CT with IV contrast for definitive dx

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2
Q

How does peritonism (localised inflammation of the peritoneum) present?

A

patients will often report their pain starts in one place (irritation of the visceral peritoneum) before localising to one area (irritation of the parietal peritoneum) or becoming generalised.

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3
Q

What intial investigations are required for the ‘acute abdomen’?

A

Routine bloods– FBC, U&Es, LFTs, CRP, amylase, and a G&S (crossmatch if blood products or urgent surgery required)

Urine dipstick – for signs of infection or haematuria
- pregnancy test is performed for all women of reproductive age

ABG– useful in bleeding or acutely unwell patients for assessment of tissue hypoperfusion and rapid haemoglobin level

ECG– to assess for potential referred myocardial pain and for pre-op work-up if any surgery required

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4
Q

What imaging is required for the ‘acute abdomen’?

A

An erect CXR – for evidence of free abdominal air or lower lobe lung pathology

USS- most useful in assessing the renal tract (for hydronephrosis and cortico-medullary differentiation), biliary tree and liver (for gallstones, gallbladder thickening, or duct dilatation), and the uterus and adenexa (particularly if a transvaginal scan)

CT abdo pelvis - most useful in assessing for pathology in the GI tract e.g. bowel perf

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5
Q

Define haematemesis

A

vomiting fresh blood

Due to bleeding in Upper GI tract

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6
Q

Causes of haematemesis?

A

Oesophageal varices
Oesophagitis
Peptic ulcer disease
Mallory Weiss Tear

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7
Q

What should you ask in a hx of haematemesis?

A

Features of haematemesis – timing, frequency, and the volume of bleeding

Associated symptoms – including dyspepsia, dysphagia, melena, or weight loss

Past medical history – including the smoking & alcohol status

Drug history – use of steroids, NSAIDs, anticoagulants, or bisphosphonates

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8
Q

What should you assess for in examination of haematemesis?

A

epigastric tenderness or peritonism, hepatomegaly, and for any stigmata of liver disease

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9
Q

All patients with haematemesis must undergo what?

A

A gastroscopy - OGD

urgency determined by Glasgow-Blatchford score

If OGD is normal but ongoing bleeding suspected - CT angiogram

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10
Q

Immediate management of haematemesis due to peptic ulcer disease?

A

injections of adrenaline and cauterisation of the bleeding during endoscopy

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11
Q

How can causes of dysphagia be categorised?

A

mechanical obstruction (e.g. oesophageal cancer) or motility disorders (e.g. achalasia)

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12
Q

List some mechanical causes of dysphagia

A

Oesophageal cancer, Gastric cancer, or Head & Neck cancer
Benign oesophageal strictures
Oesophageal web (e.g. Plummer-Vinson syndrome)
Extrinsic compression (e.g. thyroid goitre)
Pharyngeal pouch
Foreign body (mainly in children)

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13
Q

List some motility related causes of dysphagia

A

Cerebrovascular accident
Achalasia
Diffuse oesophageal spasm
Myasthenia gravis
Muscular dystrophy

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14
Q

What should you ask in a hx of dysphagia?

A

exact nature of the symptom, including duration and frequency

clarify further:
Is there difficulty in initiating the swallowing action?
Do you cough after swallowing?
Do you have to swallow a few times to get the food to pass your throat?
Is it inability to swallow or pain on swallowing (odynophagia)?

Associated sxs: reflux or dyspepsia, hoarse voice, or referred pain (to neck or ear)

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15
Q

What should you examine in a patient presenting with dysphagia?

A

overt motor dysfunction, resting tremor, or dysarthria- point towards neuromuscular cause

examine the mouth for any obvious oral disease and examine the neck for any lymphadenopathy

Examine the abdomen for palpable masses

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16
Q

What is a Gastric Outlet Obstruction (GOO)?

A

a mechanical obstruction of the proximal GI tract, occurring at some level between the gastric pylorus and the proximal duodenum, resulting in an inability in the stomach to empty

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17
Q

What can cause a GOO?

A

peptic ulcer disease ( stricturing of the stomach/duodenum)
gastric cancer or small bowel cancer
iatrogenic
pancreatic pseudocyst
Bouveret Syndrome
gastric bezoar

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18
Q

Main differential for GOO?

A

gastroparesis, where patients have delayed gastric emptying - caused by neuromuscular dysfunction not mechanical obstruction, endoscopy / CT can differentiate

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19
Q

How might GOO present?

A

epigastric pain, postprandial vomiting, and early satiety

often no change in bowel habit initially due to proximal location of obstruction

OE:
tachycardic +/- hypotensive +/- oliguric (due to hypovolaemia)
tender and distended upper abdomen
localised peritonism or guarding may be present
“succession splash” on auscultation during sudden movement

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20
Q

How should GOO be investigated?

A

routine bloods:
FBC and CRP (to assess inflammatory markers)
U&Es (to assess for AKI, in the context of dehydration and hypovolaemia)
clotting screen and Group and Save (for work-up for surgery)

Abdo XR may show a gastric fluid level, however most cases will warrant a CT scan with IV contrast

Depending on the suspected underlying cause, a upper GI endoscopy can be performed (following stomach decompression)
- used to confirm the diagnosis (e.g. biopsy) and for therapeutic purposes

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21
Q

What is Bouvret syndrome?

A

GOO secondary to a gallstone impacted at the pylorus or proximal duodenum

occurs in patients with a cholecystoduodenal fistula, usually due to recurrent cholecystitis

attempt endoscopic removal then try enterotomy

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22
Q

How should GOO be managed?

A

resuscitation with IV fluids and catheterisation
NG tube to decompress the stomach (most important step)
IV PPI

In certain cases:
endoscopy to dilate benign stricturing (either balloon dilatation or stenting) or remove any luminal obstruction (bezoars, gallstones)

In most cases the mainstay of mx is surgical:
primary resection or gastrojejunostomy to bypass obstruction depending on underlying issue

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23
Q

What is a bowel obstruction?

A

mechanical blockage of the bowel, where a structural pathology physically blocks the passage of intestinal contents

Once the bowel segment has become occluded, gross dilatation of the proximal limb of the bowel occurs →
increased peristalsis of the bowel→secretion of large volumes of electrolyte-rich fluid into the bowel (‘third spacing’)

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24
Q

What can cause the bowel to be adynamic and not work properly without a mechanical obstruction?

A

Ileus
Pseudo-obstruction

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25
Q

What is a closed loop bowel obstruction?

A

In patients with a mechanical bowel obstruction where there is a second separate obstructing point proximally (e.g. a large bowel obstruction with a competent ileocaecal valve)

surgical emergency→if not corrected, the bowel will continue to distend within a closed segment, stretching the bowel wall until it becomes ischaemic→ may perforate!!

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26
Q

What are the most common causes of bowel obstruction?

A

depends on location

Small bowel – adhesions or hernia
Large bowel – malignancy, diverticular disease, or volvulus

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27
Q

Give 3 intraluminal causes of bowel obstruction

A

Gallstone ileus, ingested foreign body, faecal impaction

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28
Q

Give some mural causes of bowel obstruction

A

Cancer
inflammatory strictures (esp in Crohn’s)
diverticular strictures
intussusception (usually in kids)
Meckel’s diverticulum
lymphoma

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29
Q

Give 4 extramural causes of bowel obstruction

A

Hernias, adhesions, peritoneal metastasis, volvulus

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30
Q

How does bowel obstruction present?

A

Abdominal pain – colicky or cramping (secondary to the bowel peristalsis)

Vomiting – occurring early in proximal obstruction and late in distal obstruction

Abdominal distension

Absolute constipation – occurring early in distal obstruction and late in proximal obstruction

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31
Q

What can be found on examination of bowel obstruction?

A

evidence of the underlying cause (e.g. surgical scars, cachexia from malignancy, or obvious hernia)

abdominal distension

focal tenderness (including guarding and rebound tenderness on palpation- only present if ischaemia developing)

percussion = tympanic sound
auscultation = ‘tinkling’ bowel sounds

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32
Q

Why should you assess fluid status in bowel obstruction?

A

may have significant third spacing

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33
Q

Differentials for bowel obstruction?

A

pseudo-obstruction
paralytic ileus
toxic megacolon
constipation

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34
Q

Investigations for bowel obstruction?

A

urgent bloods including Group & Save
monitor renal function and U&Es (risk of 3rd spacing)
VBG for metabolic derangement

Imaging:
CT with IV contrast is the mainstay
AXR sometimes used

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35
Q

Signs of small bowel obstruction on AXR?

A

Dilated bowel (>3cm), central abdominal location, and valvulae conniventes visible (lines completely crossing the bowel)

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36
Q

Signs of large bowel obstruction on AXR?

A

Dilated bowel (>6cm, or >9cm if at the caecum), peripheral location, and haustral lines visible (lines not completely crossing the bowel, ‘indents that go Halfway are Haustra’)

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37
Q

What is the conservative management of bowel obstruction? What should you do if it does not appear to be resolving?

A

In the absence of ischaemia or perforation, initial management for adhesional bowel obstruction is conservative : ‘DRIP AND SUCK’

drip : start IV fluids and correct electrolyte disturbances (+ urinary catheter and fluid balance)

suck: make patient NBM and insert and NG tube to decompress bowel

adequate analgesia

If it doesn’t resolve with conservative management : water soluble contrast study (e.g Gastrograffin)
AXR after around 6hrs since oral contrast to see evidence of ongoing obstruction versus resolution

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38
Q

When is surgical intervention indicated for bowel obstruction? What are the options?

A

Indications:
Suspicion of intestinal ischaemia or closed loop bowel obstruction
A cause that requires surgical correction (such as a strangulated hernia or obstructing tumour)
If patients fail to improve with conservative measures (typically after ≥48 hours)

Mainstay = laparotomy
If bowel resection is required, the re-joining of obstructed bowel is often not possible and a defunctioning stoma may be necessary

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39
Q

What are the complications of bowel obstruction?

A

bowel ischaemia or bowel perforation leading to faecal peritonitis (high mortality)

AKI and end organ injury due to fluid depletion

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40
Q

Why should GI perforation be one of the first diagnoses considered in all patients who present with acute abdominal pain?

A

Delay in resuscitation and definitive surgery of any perforation will progress rapidly into septic shock, multi organ dysfunction, and death

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41
Q

Causes of Upper GI perforation?

A

Peptic ulcer disease
Gastric cancer or oesophageal cancer
Foreign body ingestion (e.g. battery or caustic soda)
Excessive vomiting (Boerhaave Syndrome)

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42
Q

Causes of lower GI perforation?

A

Diverticulitis
Colorectal cancer
Appendicitis or Meckel’s Diverticulitis
Foreign body insertion
Severe colitis, such as Crohn’s Disease
Toxic megacolon (e.g. from C .Diff or UC)

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43
Q

What can cause GI perforation anywhere along the tract?

A

TIMO

Trauma
Iatrogenic, such as during gastroscopy or colonoscopy
Mesenteric ischaemia
Obstructing lesions (e.g. cancer, bezoar, or faeces)

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44
Q

Investigations for suspected GI perforation?

A

same bloods as for any patient with an acute abdomen : FBC, U&Es, LFTs, CRP, clotting, and G&S

will have raised WCC and CRP
maybe signs of end organ damage e.g. AKI or coagulopathy due to sepsis

Imaging:
CT with IV contrast is gold standard (or oral contrast in suspected Upper GI)

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45
Q

What would you see on X-ray in a GI perf?

A

CXR: air under the diaphragm in cases of pneumoperitoneum

AXR: Rigler’s sign (both sides of the bowel visible), or psoas sign (loss of the sharp delineation of the psoas muscle border)

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46
Q

Management of suspected GI perf?

A

General:
early broad spectrum abx
NBM and NG tube insertion
IV fluid resuscitation and analgesia

management then depends on underlying cause - perforated viscus usually goes to theatre for repair and contamination control

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47
Q

The key aspects of any surgical intervention for a GI perforation are:

A

Identification of the underlying cause
Appropriate management of perforation
Thorough washout

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48
Q

How is a peptic ulcer perf managed surgically?

A

accessed typically either open or laparoscopically and a patch of omentum (termed a “Graham patch”) is tacked loosely over the ulcer

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49
Q

How is a small bowel perf managed surgically?

A

bowel resection +/- primary anastomosis +/- stoma formation

on occasion, small perforations (e.g. a fish bone perforation) can be managed by oversewing the defect

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50
Q

How is a large bowel perf managed surgically?

A

high risk of contamination

bowel resection +/- stoma formation

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51
Q

Who is suitable for conservative management of a GI perf?

A

Localised diverticular perforation with only localised peritonitis and tenderness, and no evidence of generalised contamination

Patients with a sealed upper GI perforation on CT imaging without generalised peritonism

Elderly frail patients with extensive co-morbidities who would be very unlikely to survive surgery

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52
Q

What is melaena?

A

black tarry offensive smelling stool usually caused by Upper GI bleeding

often difficult to flush

caused by alteration of digested blood by intestinal enzymes

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53
Q

The key facts to ascertain from a patient presenting with melena are:

A

Colour and texture of the stool – best described as a jet black, tar-like, and sticky

Associated symptoms – including any haematemesis, abdominal pain, weight loss, dyspepsia, or dysphagia

Past medical history – including smoking and alcohol status

Drug history – use of steroids, NSAIDs, anticoagulants, or iron tablets

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54
Q

Examinations for patients presenting with melaena?

A

Abdo exam and DRE

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55
Q

All patients with new onset melaena must undergo what?

A

An OGD - urgency determined by Glasgow-Blatchford score

If OGD inconclusive:

CT angiogram - assessing for any active bleeding, especially in those with suspected ongoing bleeding or haemodynamic compromise

Colonoscopy - especially if haemodynamically stable, to ensure that the cause of the melena is not actually proximal colonic in origin (e.g. a caecal tumour)

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56
Q

What causes appendicitis?

A

direct luminal obstruction

usually secondary to a faecolith

can also be due to lymphoid hyperplasia, impacted stool or (rarely) an appendiceal or caecal tumour

when obstructed commensal bacteria multiply and cause inflammation

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57
Q

Risk factors for appendicitis?

A

most common in patients between 20-30yrs

Family history
- twin studies suggest that genetics = 30% of risk

Ethnicity
- more common in Caucasians

Environmental
-seasonal presentation during the summer

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58
Q

Clinical features of appendicitis?

A

abdo pain

  1. initially peri-umbilical, classically dull and poorly localised (from visceral peritoneum inflammation)
  2. later migrates to RIF, where it is well-localised and sharp (from parietal peritoneum inflammation)

anorexia and N+V

OE: rebound tenderness and percussion pain over McBurney’s point (2/3 of the way between umbilicus and ASIS)

59
Q

What 2 specific signs can be found O.E of appendicitis?

A

Rovsing’s sign: RIF fossa pain on palpation of the LIF

Psoas sign: RIF pain with extension of the right hip
Specifically suggests an inflamed appendix abutting psoas major muscle in a retrocaecal position

60
Q

How can appendicitis present in children?
What should you be sure to examine?

A

a high proportion of acute appendicitis in children will present atypically - diarrhoea, urinary symptoms, or even left sided pain

examine cardioresp and urinary systems as well as GI
genital examination in all boys, to exclude testicular torsion or epididymitis

61
Q

Remember, a child under 6 years of age who has had symptoms of acute appendicitis for over 48 hours is much more likely to have what?

A

A perforation!!!

Requires active observation

62
Q

Differentials for appendicitis?

A

Gynaecological: ovarian cyst rupture, ectopic pregnancy, PID

Urological: testicular torsion, epididymo-orchitis

Renal: ureteric stones, UTI, pyelonephritis

Gastrointestinal: inflammatory bowel disease, Meckel’s diverticulum, or diverticular disease

63
Q

What are the best risk stratification systems for appendicitis in men women and children?

A

Men – Appendicitis Inflammatory Response Score
Women – Adult Appendicitis Score
Children – Shera score

64
Q

What is the management for appendicitis with an appendiceal mass?

A

antibiotic therapy is favoured, with an interval appendectomy performed approximately 6-8 weeks later

65
Q

What is the gold standard surgical intervention for appendicitis?

A

Laparascopic appendectomy- low morbidity and allows better visualisation of ovaries and uterus

appendix should routinely be sent to histopathology to look for malignancy

abdomen should be inspected for other pathology including Meckel’s diverticulum

66
Q

Complications of acute appendicitis?

A

Perforation - if left untreated the appendix can perforate and cause peritoneal contamination
(esp in children who may have a delayed presentation)

Surgical site infection

Appendix mass - omentum and small bowel adhere to the appendix

Pelvic abscess
- presents as fever with a palpable RIF mass, can be confirmed w CT scan ; management is usually with abx and percutaneous drainage of abscess

67
Q

What is Pseudo-obstruction? (also known as Ogilvie syndrome)

Where does it most commonly affect?

A

dilatation of the colon due to an adynamic bowel, in the absence of mechanical obstruction

most commonly affects the caecum and ascending colon

thought to be due to an interruption of the autonomic nervous supply to the colon

68
Q

What can cause pseudo-obstruction?

  • it MEaNT to look like an obstruction :)
A

Medication
- opioids, CCBs, or anti-depressants

Electrolyte imbalance or endocrine disorders
- hypercalcaemia, hypothyroidism, or hypomagnesaemia

Neurological disease
- Parkinson’s disease, Multiple Sclerosis, and Hirschsprung’s disease

Trauma - recent surgery, severe illness, or trauma
- incl. cardiac ischaemia

69
Q

Clinical features of pseudo-obstruction?

A

same as for mechanical obstruction

  1. Abdominal pain and distension
  2. Constipation
    • whilst not passing ‘normal’ stool, often patients
      may have paradoxical diarrhoea
  3. Vomiting
    • late feature due to the colon being most distal in
      the GI tract

On examination, the abdomen will be distended and tympanic

70
Q

Investigations for pseudo-obstruction?

A

blood tests - assess for biochemical or endocrine causes of pseudo-obstruction, including U&Es, Ca2+, Mg2+, and TFTs

CT abdo-pelvis with IV contrast - rule out mechanical cause

Motility studies will often be required in the long-term

71
Q

How should cases of pseudo-obstruction that do not resolve within 24-48 hours be managed?

A

endoscopic decompression = mainstay of treatment (insertion of flatus tube)

if limited resolution, use of IV neostigmine (an anticholinesterase) may be trialled

72
Q

Outline the 2 types of inguinal hernia and the patient groups they occur in

A

Direct inguinal hernia (20%)
- Bowel enters the inguinal canal directly through a weakness in the posterior wall (Hesselbach’s triangle)
- medial to inferior epigastrics
- older patients, often secondary to abdominal wall laxity or a significant increase in intra-abdominal pressure

Indirect inguinal hernia (80%)
- Bowel enters the inguinal canal via the deep inguinal ring
- lateral to inferior epigastrics
- due to incomplete closure of the processus vaginalis, congenital in origin

73
Q

Risk factors for inguinal hernia?

A

Male gender
Increasing age
Raised intra-abdominal pressure, from chronic cough, heavy lifting, or chronic constipation
High BMI

74
Q

What specific features should be noted on examination for inguinal hernia?

A

Location – inguinal hernias appear superomedial to the pubic tubercle (whilst femoral hernias appear inferolateral to the pubic tubercle)

Cough impulse – an irreducible hernia may not have a cough impulse

Reducible – On lying down or with gentle pressure

If it enters the scrotum, can you get above it / is it separate from the testis

75
Q

How can you differentiate between the 2 types of inguinal hernia?

A

reduce the hernia and then place pressure over the deep inguinal ring (located at the mid-point of the inguinal ligament), before asking the patient to cough

If the hernia protrudes despite occlusion of the deep inguinal ring, this indicates a direct hernia

This is often unreliable and surgical exploration is more definitive

76
Q

Differentials for an inguinal hernia?

A

Groin lump: femoral hernia, saphena varix, inguinal lymphadenopathy, lipoma, or groin abscess

77
Q

How should an inguinal hernia be investigated?

A

clinical diagnosis, imaging only required if diagnostic uncertainty

USS first line
CT imaging if features of obstruction or strangulation

78
Q

What are the options for hernia repair?

A

open repair (Lichtenstein technique) or laparoscopic repair (either total extraperitoneal (TEP) or transabdominal pre-peritoneal (TAPP))

open mesh repairs are preferred for those with primary inguinal hernias

laparoscopic approach is preferred in those with bilateral or recurrent inguinal hernias

can also be considered in patients with a primary unilateral hernia if:
1. at a high risk of chronic pain (young and active, previous chronic pain,predominant symptom of pain)
2. female (due to the increased risk of the presence of a femoral hernia)

79
Q

The serious complications of a hernia that require urgent intervention are:

A

Irreducible / incarcerated – the contents of the hernia are unable to return to their original cavity

Obstruction – the bowel lumen has become obstructed, leading to the clinical features of bowel obstruction

Strangulation – compression of the hernia has compromised the blood supply, leading to the bowel becoming ischaemic

80
Q

Complications of inguinal hernias? complications of surgical repair?

A

incarceration, strangulation, and obstruction

complications following elective hernia repair:
haematoma or seroma formation
recurrence
chronic pain
damage to vas deferens or testicular vessels

81
Q

Femoral herniae are relatively uncommon. Why are they an important problem?

A

High risk of strangulation due to narrow neck

82
Q

Risk factors for developing a femoral hernia?

A

Female (3:1 F:M)
Pregnancy (higher incidence in multiparous women)
Raised intra-abdominal pressure (e.g. heavy lifting, chronic constipation)
Increasing age

83
Q

What is Athletic Pubalgia?

A

impingement of abdominal wall musculature due to small tear in rectus sheath, common in young athletes

84
Q

All femoral hernias should be managed surgically, ideally within 2 weeks of presentation, due to the high risk of strangulation.

What are the 2 different surgical approaches?

A

Low approach – incision made below the inguinal ligament
+ doesn’t interfere with the inguinal structures
- limited space for the removal of any compromised small bowel

High approach – the incision is made above the inguinal ligament
+ is the preferred technique in an emergency intervention due to the easy access to compromised small bowel

85
Q

Key features of an epigastric hernia?

A

herniates in upper midline through the fibres of the linea alba

asymptomatic or midline mass that disappears when lying on back

mostly in middle aged men

important differential diagnosis is divarication of the recti

86
Q

Key features of a paraumbilical hernia?

A

through the linea alba around the umbilical region

usually secondary to raised intra-abdominal pressure, risk factors include obesity and pregnancy

generally contain pre-peritoneal fat, do not commonly strangulate

87
Q

Key features of a spigelian hernia?

A

occurs around the level of the arcuate line

small tender mass at the lower lateral edge of the rectus abdominus

high risk of strangulation, urgent repair required

88
Q

Key features of an obturator hernia?

A

hernia of the pelvic floor, occurring through the obturator foramen into the obturator canal

more common in women (due to a wider pelvis), typically in elderly patients

present with a mass in the upper medial thigh and often features of small bowel obstruction

50% have compression of the obturator nerve and
+ve Howship-Romberg sign

89
Q

What are Richter’s herniae?

A

partial herniation of bowel involving the anti-mesenteric border

90
Q

What are the basic principles of wound management?

A

Haemostasis
Cleaning the wound
Analgesia
Skin closure
Dressing and follow-up advice

91
Q

What are the 5 aspects of wound cleaning?

A
  1. Disinfect the skin around the wound with antiseptic
    (avoid getting alcohol or detergents inside the wound)
  2. Decontaminate the wound by manually removing any foreign bodies
  3. Debride any devitalised tissue where possible
  4. Irrigate the wound with saline
    - if no obvious contamination present, low pressure irrigation is sufficient (pouring normal saline from a sterile container carefully into the wound)
  5. Antibiotics for high-risk wounds or signs of infection
92
Q

Risk factors for wound infection?

A

foreign body present or heavily soiled wounds, bites (including human), puncture wounds, and open fractures

93
Q

What is the maximum level of local anaesthetic given for wound closure?

A

maximum level of lidocaine is 3mg/kg and the addition of adrenaline allows for up to 7mg/kg

remember to not use adrenaline with local anaesthetic if administering in or near appendages (e.g. a finger)

94
Q

4 main methods of manually opposing a wound?

A
  1. Skin adhesive strips (e.g. Steri-StripsTM) are suitable if no risk factors for infection are present
  2. Tissue adhesive glue (e.g. Indermil) - used for small lacerations with easily opposable edges (a popular choice in paeds)
  3. Sutures - used for any laceration greater than 5cm, deep dermal wounds, or in locations that are prone to flexion, tension, or wetting
  4. Staples can be used for some scalp wounds
95
Q

How should you apply a wound dressing to a non-infected laceration?

A

the first layer should be non-adherent (such as a saline-soaked gauze), followed by an absorbent material to attract any wound exudate, and finally soft gauze tape to secure the dressing in place

96
Q

When should sutures or adhesive strips be removed?

A

sutures or adhesive strips should be removed 10-14 days after initial would closure (or 3-5 days if on the head)

tissue adhesive glue will naturally slough off after 1-2 weeks

97
Q

Why are malnourished patients poor surgical candidates?

A

Surgery causes physiological stress with a resultant hyper-metabolic state and catabolic response

Malnourished patients are at increased risk of post-operative complications, such as reduced wound healing, increased infection rates, and skin breakdown

98
Q

Outline the simple hierarchy of feeding methods that should be used for surgical patients

A

If unable to eat sufficient calories - Oral nutritional Supplements (ONS)

If unable to take sufficient calories orally or dysfunctional swallow - Nasogastric tube feeding (NGT)

If oesophagus blocked/dysfunctional - Gastrostomy feeding (PEG/RIG)

If stomach inaccessible or outflow obstruction- Jejunal feeding (jejunostomy)

If jejunum inaccessible or intestinal failure (IF) - Parenteral nutrition

99
Q

What is the stepwise approach to tx in patients with intestinal failure?

A

SNAP

Sepsis – Any overwhelming infection present must be corrected otherwise feeding will be largely useless

Nutrition – Once the infection is corrected, suitable nutritional support should be provided

Anatomy – Define the anatomy of the GI tract so that surgery can be planned

Procedure – Definitive surgery once any infection eradicated, the patient nourished, and the anatomy defined

100
Q

What are the principles of Enhanced Recovery After Surgery (ERAS)?

A

Reduction in ‘Nil By Mouth’ times (clear fluids up to 2 hours pre-surgery)
Pre-operative carbohydrate loading
Minimally invasive surgery
Minimising the use of drains and nasogastric tubes
Rapid reintroduction of feeding post-operatively
Early mobilisation

101
Q

When after uncomplicated GI surgery can a patient safely tolerate an enteral diet?

A

after 24 hrs

102
Q

What are the options for nutritional management of Entero-cutaneous Fistulae (ECF)?

A

dependent upon the level of the fistula so imaging often required to decide how to manage effectively

High fistula (jejunal) may need support with enteral or parenteral nutrition

Low fistulae (ileum/colon) can be treated with low fibre diet

103
Q

The nutritional support and treatment for High Output Stoma (HOS) is dependent upon the length of bowel to stoma.

Outline the nutritional requirements for different positions of jejunostomy

A

Distance From DJ Flexure to Jejunostomy :

150-200cm = Enteral support
100-150cm =Enteral support +/- IV fluids
<100cm = Parenteral Nutrition

104
Q

Outline the nutritional requirements for different positions of colostomy

A

Distance From DJ Flexure to Colostomy:

100-150cm = Enteral support
50-100cm = Enteral support +/- IV fluids
<50cm = Parenteral Nutrition

105
Q

Once active disease or infection has been excluded, then a reduction in stoma output can be achieved by:

A
  1. Reduction in hypotonic fluids to 500ml/day
  2. Reduction in gut motility with high dose loperamide and codeine phosphate
  3. Reduction in secretions with high dose PPI (a twice daily dose)
  4. Use of WHO solution to reduce sodium losses
  5. Low fibre diet to reduce intraluminal retention of water
106
Q

What ECG pattern indicates severe hyperkalaemia?

A

A sinusoidal ECG pattern - (K > 9 mmol/L)

107
Q

List some key causes of RIF pain

A

Appendicitis
Crohn’s
Mesenteric Adenitis
Diverticulitis
Meckel’s Diverticulitis
Incarcerated right inguinal or femoral hernia
Bowel perf
Gynae/uro causes

108
Q

Causes of abdo swelling?

A

Pregnancy

Ascites -History of alcohol excess, cardiac failure

Intestinal obstruction- History of malignancy/previous operations, vomiting, ‘tinkling’ bowel sounds

Urinary retention - History of prostate problems
Dullness to percussion around suprapubic area

Ovarian cancer - Older female, Pelvic pain
Urinary symptoms e.g. urgency
Raised CA125
Early satiety, bloating

109
Q

Factors that increase the risk of abdominal wound dehiscence?

A

Malnutrition
Vitamin deficiencies
Jaundice
Steroid use
Major wound contamination (e.g. faecal peritonitis)
Poor surgical technique (Mass closure technique is the preferred method-Jenkins Rule)

110
Q

Mx of abdominal wound dehiscence?

A

Coverage of the wound with saline soaked gauze (on the ward)
IV broad-spectrum antibiotics and fluids
Analgesia
Arrangements made for a return to theatre

111
Q

Key questions to ask for groin lumps?

A

Is there a cough impulse?
Is it pulsatile AND is it expansile (to distinguish between false and true aneurysm)?
Are both testes intra scrotal?
Any lesions in the legs such as malignancy or infections (?lymph nodes)
Examine the ano rectum as anal cancer may metastasise to the groin
Is the lump soft, small and very superficial (?lipoma)

112
Q

Key questions to ask for scrotal lumps?

A

Is the lump entirely intra scrotal?
Does it transilluminate (?hydrocele)
Is there a cough impulse (?hernia)

113
Q

Indications for surgery in lower GI bleeding?

A

Patients > 60 years
Continued bleeding despite endoscopic intervention
Recurrent bleeding
Known cardiovascular disease with poor response to hypotension

114
Q

Key management steps of lower GI bleeding?

A

All patients should have a history and examination, PR and proctoscopy

Colonoscopic haemostasis aimed for in post polypectomy or diverticular bleeding

115
Q

Massive haemorrhage is the loss of one blood volume in a 24 hour period or the loss of 50% of the circulating blood volume in 3 hours.

Complications of tx for massive haemorrhage?

A

Hypothermia - Blood is refrigerated, shifts Bohr curve to the left

Hypocalcaemia - Both FFP and platelets contain citrate anticoagulant which may chelate calcium

Hyperkalaemia - Plasma of red cells stored for 4-5 weeks contains 5-10 mmol K+

Coagulopathy - Anticipate once circulating blood volume transfused
1 blood volume usually drops platelet count to 100 or less and dilutes and clotting factors

Delayed type transfusion reactions - Due to minor incompatibility issues especially if urgent or non cross matched blood used

Transfusion related lung injury - Acute onset non cardiogenic pulmonary oedema
- leading cause of transfusion related deaths
- occurs as a result of leucocyte antibodies in transfused plasma and aggregation and degranulation of leucocytes in lung tissue

116
Q

What nerve lesions may result from:
Posterior triangle lymph node biopsy
Carotid endarterectomy
Thyroidectomy
Anterior resection of rectum
Axillary node clearance
Inguinal hernia surgery
Varicose vein surgery
Posterior approach to the hip

A

Posterior triangle lymph node biopsy = accessory nerve lesion

Carotid endarterectomy = hypoglossal nerve

Thyroidectomy = laryngeal nerve

Anterior resection of rectum = hypogastric autonomic nerves

Axillary node clearance = long thoracic nerve, thoracodorsal nerve and intercostobrachial nerve

Inguinal hernia surgery = ilioinguinal nerve

Varicose vein surgery = sural and saphenous nerves

Posterior approach to the hip = sciatic nerve

117
Q

A pathological fracture occurs in abnormal bone due to insignificant injury. Give some underlying causes

A

Metastatic tumours:
Breast , Bronchus (Lung) , Bhyroid , Bidneys , Brostate

Primary malignant tumours
Chondrosarcoma , Osteosarcoma , Ewing’s tumour

Bone disease
Osteogenesis imperfecta, Osteoporosis, Paget’s disease

Local benign conditions
Chronic osteomyelitis, Solitary bone cyst

118
Q

5 main causes of shock?

A

Septic
Haemorrhagic
Neurogenic
Cardiogenic
Anaphylactic

119
Q

What is required to meet the diagnostic criteria for sepsis?

A

infections and two or more elements of SIRS (systemic inflammatory response syndrome)

body temperature outside 36 oC - 38 o C, HR >90 beats/min, respiratory rate >20/min, WBC count >12,000/mm3 or < 4,000/mm3

120
Q

What causes neurogenic shock?

A

spinal cord transection, usually at a high level

decreased sympathetic tone or increased parasympathetic tone = decrease in peripheral vascular resistance and marked vasodilation

121
Q

What is flail chest?

A

When the chest wall disconnects from thoracic cage
Multiple rib fractures (at least two fractures per rib in at least two ribs)
Associated with pulmonary contusion
Abnormal chest motion
Avoid over hydration and fluid overload

122
Q

Cause of haemothorax? Mx?

A

Most commonly due to laceration of lung, intercostal vessel or internal mammary artery

Haemothoraces large enough to appear on CXR are treated with large bore chest drain
Surgical exploration (thoractomy) is warranted if >1500ml blood drained immediately or losses of >200ml per hour for >2 hours

123
Q

How can blunt cardiac injury present?

A

Usually occurs secondary to chest wall injury
ECG may show features of myocardial infarction
Sequelae: hypotension, arrhythmias, cardiac wall motion abnormalities

124
Q

Differentiate between the different types of graft:

A

Allograft - Transplant of tissue from genetically non identical donor from the same species (kidney from donor) - ‘allo there neighbour!

Isograft - Graft of tissue between two individuals who are genetically identical (kidney from twin)

Autograft - Transplantation of organs or tissues from one part of the body to another in the same individual (skin graft)

Xenograft - Tissue transplanted from another species (porcine heart valve)

125
Q

Complications of enteral feeding?

A

diarrhoea - 1 in 6 patients

aspiration

metabolic
- hyperglycaemia, refeeding syndrome

126
Q

Achalasia increases risk of which oesophageal cancer?

A

squamous cell carcinoma

127
Q

A 68 year of man presents with recurrent episodes of left sided ureteric colic and haematuria. Investigations show some dilatation of the renal pelvis but the outline is irregular. Diagnosis?

A

Transitional cell carcinoma

These arise from urothelium and necessitate a nephroureterectomy

128
Q

The Parkland formula for fluid resuscitation in burns is:

A

Volume of fluid = total body surface area of the burn % x weight (Kg) x 4ml

129
Q

Irreducible, painful lump inferolateral to the pubic tubercle →

A

?strangulated femoral hernia

130
Q

Pregnancy and frank haematuria, especially if there is a history of placenta previa or prior caesarean section, should indicate what diagnosis?

A

Placenta percreta

placental implantation into the myometrium

131
Q

A 45-year-old woman presents with haematuria and loin pain. She has a normal temp and is found to have a Hb 180 g/l and a creatinine of 156 umol/l. Her urine dipstick shows 3+ blood. Blood and urine cultures are negative.

Dx?

A

Renal vein thrombosis - common feature of renal cell carcinoma as it invades the renal vein.

132
Q

Looking for small and large bowel obstruction is one of the key indications for performing an abdominal film.

How should small bowel and large bowel appear?

A

Small bowel
Maximum normal diameter = 35 mm
Valvulae conniventes extend all the way across

Large bowel
Maximum normal diameter = 55 mm
Haustra extend about a third of the way across

133
Q

What is Boas’ sign?

A

In acute cholecystitis there is hyperaesthesia beneath the right scapula.

It occurs because the abdominal wall innervation of this region is from the spinal roots that lie at this level

134
Q

72-year-old woman with a history of congestive cardiac failure. She reports having a poor appetite and feeling bloated. She is admitted frequently to hospital with LV failure due to poor compliance with medication. Diagnosis?

A

ascites

poorly controlled HF can cause ‘cardiac cachexia’, partly due to gut oedema

135
Q

How does angiodysplasia present?

A

arteriovenous lesions, right side of colon more commonly affected

Apart from bleeding, which may be massive, these cause few symptoms

136
Q

A 17-year-old male is admitted with lower abdominal discomfort. He has been suffering from intermittent RIF pain for the past few months. His past medical history includes a negative colonoscopy and gastroscopy for iron deficiency anaemia. The pain is worse after meals. Inflammatory markers are normal.

Dx?

A

Meckel’s diverticulum - small outpouching of small intestine
- may contain ectopic gastric mucosa which may secrete acid with subsequent bleeding and ulceration

137
Q

What is Mitterlschmerz?

A

mid cycle (ovulation) pain

RIF or LIF

occurs because a small amount of fluid is released at the time of ovulation. It will usually resolve over 24-48 hours

138
Q

A 16-year-old boy presents with severe groin pain after kicking a football. Imaging confirms a pelvic fracture. A previous pelvic x-ray performed 2 weeks ago shows a lytic lesion with ‘onion type’ periosteal reaction

Dx?

A

Ewings sarcoma

is most common in males between 10-20 years

A lytic lesion with a lamellated or onion type periosteal reaction is a classical finding on x-rays

Most patients present with metastatic disease

139
Q

How should congenital inguinal hernias be managed?

A

Should be surgically repaired soon after diagnosis as at risk of incarceration

140
Q

How do infantile umbilical hernias present?

A

Symmetrical bulge under the umbilicus
More common in premature and Afro-Caribbean babies
The vast majority resolve without intervention before the age of 4-5 years
Complications are rare

141
Q

What can cause bowel obstruction of both the small and large bowel concurrently in the elderly?

A

incompetent ileocaecal valve

142
Q

Characteristic sign of bowel cancer on X-ray?

A

apple core sign with barium swallow

143
Q

A 22 year man is shot in the groin. On examination he has weak hip flexion, weak knee extension, and impaired quadriceps tendon reflex, as well as sensory deficit in the anteromedial aspect of the thigh.

What nerve has been damaged?

A

femoral nerve

Y3 Surgery (8 decks)

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